What is the standardized workup for a patient presenting with dizziness as the chief complaint?

Standardized Workup for Dizziness as a Chief Complaint

The most effective approach to evaluating dizziness is to categorize patients based on timing and triggers rather than symptom quality, as this better distinguishes between benign and dangerous causes. 1, 2

Initial Assessment Framework

Step 1: Categorize the Dizziness Pattern

Divide patients into three key categories based on timing and triggers:

1. Acute Vestibular Syndrome (AVS)

   • Sudden onset, continuous dizziness lasting days
   • Key assessment: HINTS examination (Head Impulse, Nystagmus, Test of Skew)
   • Differentiates: Vestibular neuritis (benign) vs. stroke (dangerous)

2. Spontaneous Episodic Vestibular Syndrome

   • Recurrent episodes without specific triggers
   • Key assessment: Associated symptoms
   • Differentiates: Vestibular migraine vs. TIA

3. Triggered Episodic Vestibular Syndrome

   • Episodes provoked by specific movements
   • Key assessment: Dix-Hallpike and supine roll tests
   • Differentiates: BPPV vs. posterior fossa lesions 3

Step 2: Focused Physical Examination

• Vital signs: Include orthostatic measurements (drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing indicates orthostatic hypotension) 3

• HINTS examination for AVS:

  • Head Impulse Test: Abnormal in peripheral causes, normal in central causes
  • Nystagmus: Unidirectional in peripheral causes, direction-changing in central causes
  • Test of Skew: Vertical misalignment suggests central cause
  • Note: HINTS is more sensitive than early MRI for stroke detection 3

• Dix-Hallpike maneuver for positional vertigo:

  • Positive test: Delayed onset nystagmus with latency and fatigability indicates BPPV
  • Immediate onset or persistent nystagmus suggests central cause 3

• Neurological examination:

  • Cranial nerves
  • Cerebellar function
  • Motor and sensory function
  • Gait assessment

Step 3: Targeted Diagnostic Testing

Based on clinical presentation, consider:

• Laboratory tests:

  • Complete blood count (if anemia suspected)
  • Electrolytes, glucose
  • Thyroid function tests (if relevant)

• Imaging (only when indicated):

  Indication	Imaging Modality
  AVS with abnormal HINTS examination	MRI brain (without contrast)
  AVS with neurological deficits	MRI brain (without contrast)
  High vascular risk patients with AVS	MRI brain (without contrast)
  Chronic undiagnosed dizziness not responding to treatment	MRI brain (without contrast)

• Specialized testing:

  • Consider vestibular function testing for persistent symptoms
  • ECG if cardiac cause suspected

Common Diagnoses and Management

BPPV

• Characterized by brief vertigo with position changes
• Diagnosed with positive Dix-Hallpike test
• Treatment: Canalith Repositioning Procedure (Epley maneuver) with 80% success rate 3

Vestibular Neuritis

• Presents with sudden severe vertigo lasting days
• Diagnosed by unidirectional horizontal nystagmus and normal HINTS exam
• Treatment: Early corticosteroid therapy 3

Orthostatic Hypotension

• Treatment: Medication adjustment, hydration, compression stockings, gradual position changes 3

Vestibular Migraine

• Attacks lasting hours to >24 hours, often with migraine history
• More photophobia than other vestibular disorders 3

Red Flags Requiring Urgent Evaluation

• Abnormal HINTS examination in acute vestibular syndrome
• Neurological deficits accompanying dizziness
• New-onset severe headache with dizziness
• Acute hearing loss with vertigo
• High vascular risk factors with acute dizziness 3, 1

Common Pitfalls to Avoid

• Focusing on quality of dizziness rather than timing and triggers
• Failing to perform the Dix-Hallpike maneuver in patients with positional vertigo
• Routinely prescribing vestibular suppressants for BPPV
• Missing central causes by not performing the HINTS examination
• Ordering unnecessary imaging studies in patients with clear peripheral vertigo 3

Remember that while many causes of dizziness are benign, approximately 7% of patients may suffer major morbidity or mortality related to the underlying cause 4. Patients with initial diagnoses of anemia, stroke, or diabetes represent a high-risk group (50%) for poor outcomes, while those under 50 years with peripheral vestibular disease, vasovagal or psychogenic causes form a low-risk group (2%) 4.